INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21-22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.7 (b) (1) LICENSURE Food service.
705.7. Food Service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(1) Have a food preparation area with a refrigerator, a sink, a stove, an oven and cabinet space for storage.
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Observations
Based on the physical plant inspection, the facility failed to store cooking utensils in a clean enclosed area.
The findings include:
The physical plant inspection was conducted on October 22, 2013. The facility failed to store cooking utensils in a clean enclosed area as they were stored on hanging racks, in an open area located above the food preparation area.
The facility director confirmed the findings.
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Plan of Correction
On November 8, 2013 the Kitchen Supervisor purchased a covered utensil container to store cooking utensils. The container was purchased to ensure that there is a covered cabinet space for storage of cooking utensils.
A training with the kitchen staff will be facilitated by the Kitchen Supervisor on November 12, 2013 to review standard 705.7 (b)(1).
Monthly Continuous Quality Improvement (CQI) meetings will ensure compliance with DDAP Policy 705.7 (b)(1)
Persons Responsible:
Inpatient Director
Kitchen Supervisor
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The facility's fire drill logs for the time frame of November 2012 to September 2013 were reviewed on October 21, 2013. The facility failed to conduct a fire drill during sleeping hours from November 2012 to May 2013.
The facility director confirmed the findings.
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Plan of Correction
A fire drill will be conducted in the Inpatient Men's and Women's Units during sleeping hours at least once every six months.
A Fire Drill Training with all Inpatient Program staff will be held on November 13, 2013 to review standard 705.10 (d)(1).
Monthly Continuous Quality Improvement (CQI) meetings will ensure compliance with DDAP Policy 705.10 (d)(1)
Persons Responsible:
Inpatient Director
Operations Director
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709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of the facility's policy and procedure manual and client records, the facility failed to document client follow-up information in two of four client records.
The findings include:
The facility's policy and procedure manual required that client follow-up be conducted 30 days after discharge.
Four client records that required follow-up information were reviewed on October 21-22, 2013. The facility failed to document follow-up information in client records # 7 and 8.
Client # 7 was admitted on April 22, 2013 and discharged on August 19, 2013. Based on facility policy, documentation of a follow-up attempt was due by September 19, 2013. The facility failed to document follow-up information in client record # 7 as of the date of inspection.
Client # 8 was admitted on August 6, 2013 and discharged on September 19, 2013. Based on facility policy, documentation of a follow-up attempt was due by October 19, 2013. The facility failed to document follow-up information in client record # 8 as of the date of inspection.
The facility director confirmed the findings.
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Plan of Correction
To ensure that follow up information is documented in the client record 30 days after discharge, the Inpatient Director will review all discharges on a weekly basis via a discharge log. Follow up information will then be documented by the Inpatient Director.
Training with all Inpatient Program staff will be held on November 13, 2013 to review the follow up policy per standard 709.53 (a).
Monthly Continuous Quality Improvement (CQI) meetings will ensure compliance with DDAP Policy 709.53 (a).
Persons Responsible:
Inpatient Director
Inpatient Clinical Supervisor
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